Mental Health Assessment and Plan (handwritten)

MENTAL HEALTH ASSESSMENT AND PLAN

Patient Details:

Name: _____________________________________________ DOB: ___________________

Gender:   Female  / Male

Medical History:

  

Medications:

Social History:

Occupation:

Marital status:  Single   / Married   / Defacto / Divorced  / Widowed / Other ____________

Sexual Orientation:      Heterosexual  / Homosexual / _________________

Lives with:  

Is a Carer:    No

Has a Carer: Self

Alcohol:  Non Drinker / Social Light Drinker /  _______________________

Smoking:   Non Smoker  / Ex smoker /  _______________

PART 1- MENTAL HEALTH ASSESSMENT

Reasons for Preparation of Mental Health Plan:

Outcome Measurement Tool:

Tool :  K10

Result:

Other issues:

Previous Mental Health or other behavioural Diagnosis:

Substance Abuse History:

  

RISK ASSESSMENT:

Thoughts of self harm?

Occasional  / Regularly /  Has a Plan / Other ______________________

Mental Health Assessment

Appearance and General Behaviour:   Normal / ________________

Mood:  Depressed  / Normal / _______________

Thinking:  Normal / ________________

Affect: Normal / Flat / ____________________

Perception: Normal / Abnormal ______________________

Sleep:  Normal /  Insomnia / Hypersomnia / ___________________

Cognition: Normal / ______________________

Appetite: Normal   / Not eating / Overeating / _________________

Attention and Concentration:  Normal / Reduced / _______________

Motivation and Energy:   Normal / reduced / ___________________

Memory:  Normal /  Impaired / ________________________

Judgement:  Normal / Impaired  / ________________________

Insight: Normal  / Impaired / ________________________

Anxiety Symptoms:  Emotional anxiety / Physical Anxiety / ____________________

Orientation: Oriented to time, person and place

Speech: Normal

PART 2 - PLAN

Problem:

The assessment was discussed with the patient, including mental health formulation and the diagnosis / provisional diagnosis

  

Goals:

Reduce Symptoms and improve functioning

Plan:

Treatment options were discussed with patient, including referral options and appropriate supports.

The Patient agreed to take the following actions:

___ Relaxation exercises

___ Regular Physical exercise such as walking

___ Reduce alcohol consumption

___ Try and rest  / get good sleep

___ Meditation

___ Take prescribed medications

___ Spend time with friends and positives influences

___ Eat a balanced diet

___ Reduce fatty foods / sugary drinks

Other Patient actions:

___ The patient was provided with necessary psycho-education regarding their mental health condition.  It was explained how their condition may affect their function and the effect prescribed medications may have.

Education was also provided on the effects of alcohol, poor diet and illicit drugs may have on their mental health.

The following items will also be performed as part of the Mental Health Plan:

___ Referral to psychologist

___ Commence Psychotropic medication

___ Continue psychotropic medication

___ GP counselling and regular review

                                           

Emergency Care

1. Return to GP

2. Family support

3. Call Acute Care Team at their local Hospital

4. If unable to get through to ACT, call 000 

GP Declaration: 

• Patient understands their condition and the purpose of the this mental health assessment and plan
• The patient has verbally agreed to this plan and the proposed goals and action
• Patient has been provided with a copy of this plan

 GP Signature

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